Agreement of minimally invasive pulse wave analysis with pulmonary artery and transpulmonary thermodilution cardiac output measurements in perioperative and intensive care medicine: a systematic review and meta-analysis

Background Cardiac output monitoring is recommended for high-risk surgical patients and critically ill patients with circulatory shock. We performed a systematic review and meta-analysis of clinical studies published since 2010 that compared minimally invasive pulse wave analysis-derived cardiac output or cardiac index measurements with reference measurements by pulmonary artery thermodilution or transpulmonary thermodilution in adult surgical or critically ill patients. Methods In a random-effects meta-analysis, we calculated pooled estimates of the percentage error, mean difference and standard deviation, and 95% limits of agreement separately for studies reporting cardiac output or cardiac index. Subgroup analyses were performed by patient population and test device. Results We included 92 studies divided into 113 data sets with a total of 3111 patients. For 71 data sets reporting cardiac output, the pooled percentage error (95% confidence interval [95% CI]) was 44.0% (38.2%–49.8%) with a mean difference (standard deviation) of -0.1 (1.3) L min −1 with 95% LoA of -2.6 to 2.4 L min −1 (I 2 =9.8%). For 42 data sets reporting cardiac index, the pooled percentage error was 49.1% (40.6%–57.6%) with a mean difference of -0.1 (0.9) L min −1 m −2 with 95% limits of agreement of -1.8 to 1.6 L min −1 m −2 (I 2 =7.9%). The percentage error varied substantially across patient populations and devices. Overall risk of bias was low. Conclusions The pooled percentage error between minimally invasive pulse wave analysis-derived cardiac output measurements of 44.0% (cardiac output) and 49.1% (cardiac index) in adult surgical or critically ill patients exceeds the 30% threshold for clinically acceptable agreement. However, the percentage error varied depending on the patient population and device used. Trial Registration. PROSPERO (CRD420251090806; submitted July 17, 2025).